Perianal abscess and fistula-in-ano in infants.
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Abscess↗
Biomedical subjects
J M Laberge
Publications and source records attributed to J M Laberge.
Injection sclerotherapy in the treatment of rectal prolapse in infants and children.
PURPOSE: The aim of this study was to examine the efficacy of injection sclerotherapy as treatment for persistent rectal prolapse. METHODS: The records of 28 patients with rectal prolapse treated with injection sclerotherapy over a 16-year period were reviewed. Initial management included assessment and correction of predisposing factors. If rectal prolapse persisted or if the prolapse required repeat emergency or operating room reduction, injection sclerotherapy was performed. The sclerosing agent included D50W in 21 patients (sole agent in 15, combined with ethanolamine oleate in four, and with phenol 5% in two). Phenol 5% alone was used in six patients, and 25% saline was used in one patient. Number of injections, recurrences, and complications were reviewed. RESULTS: Two patients were lost to follow-up, and one patient was cured once a polyp was recognized and removed. Of the remaining 25 patients, 21 were cured. Sixteen required one injection, three required two injections, and two required three injections (64% cure rate after one injection, 84% cure rate after three injections). There were 4 of 25 failures: two went on to low anterior resection after having failed two injections each; one patient was treated with Thiersch cerclage and injection after two failed injections; and one patient did not respond after three injections but had less severe prolapses. Of those injected with D50W alone, 13 of 14 were cured with injection sclerotherapy. Nine received one injection, two received two injections, and two received three injections (64% cure rate after one injection, 93% cure rate after three injections). The only complication was excessive oozing at the injection site in one patient. He was simply observed in hospital overnight. Follow-up averaged 33 months. The only significant underlying abnormality in our patient population was spina bifida in one patient. This patient was cured with injection therapy. Cystic fibrosis was ruled out by clinical examination and sweat chloride test in all patients. Constipation was the most common condition identified with the onset of rectal prolapse (15 of 28). CONCLUSIONS: Injection sclerotherapy is simple and should be considered as the first line treatment of recurrent rectal prolapse after failure of conservative measures. D50W is effective, easily available, inexpensive, and associated with few complications.
Causality↗
The plug-unplug sequence: an important step to achieve type II pneumocyte maturation in the fetal lamb model.
PURPOSE: The purpose of this study was to test the hypothesis that tracheal obstruction (plugging) in the fetal lamb model leads to a decrease in the absolute number of type II pneumocytes and that reversing the obstruction before birth (unplugging), allows the type II cells to recover while maintaining the beneficial effect on lung growth. METHODS: Nine time-dated pregnant ewes (term, 145 days), carrying 17 fetuses, were used in this surgical trial. The fetuses were divided into three experimental groups: group A underwent plugging at 93 days gestation, followed by unplugging at 110 days; group B animals had tracheal ligation at 93 days and group C consisted of unoperated controls. All fetuses were delivered by cesarean section at 136 days' gestation. The fetal trachea was obstructed with the tracheoscopically placed detachable balloon described by our group. Unplugging was performed by needle puncture of the balloon under tracheoscopic vision. Outcome measurements consisted of lung-to-body-weight ratio (LWBR), lung morphometry (mean terminal bronchial density [MTBD] and linear intercept [Lm]), and assessment of the number of type II pneumocytes. The latter was determined by in situ hybridization to the mRNA of surfactant protein-C, which is exclusively produced by type II cells. Statistics were calculated using a two-tailed unpaired t test and P less than .05 is considered significant. RESULTS: Seventeen animals are included in the results. All of them had lung samples analyzed for lung morphometry, whereas for type II cells analysis, three animals were studied in each group. Morphometric analyses were consistent with pulmonary hyperplasia for group B, whereas group A lungs showed more histological maturity than group C albeit not as marked as group B. In group A, there was a similar number of type II cells to that observed in group C (53.2 +/- 3.9 v 55.9 +/- 4.0, P = .66). However, for group B animals, the number of type II pneumocytes was markedly decreased compared with controls (4.7 +/- 0.1 v 55.9 +/- 4, P = .0003). CONCLUSIONS: The authors conclude that tracheal ligation until birth, although inducing pulmonary hyperplasia, significantly decreases the number of type II pneumocytes in the alveoli. After a temporary 15-day occlusion initiated at 95 days' gestation, there is complete normalization of the density of type II cells. These results bear importance on the duration of PLUG to treat the pulmonary hypoplasia seen in congenital diaphragmatic hernia. Temporary tracheal obstruction now needs to be tested in a hypoplastic lung model.
Animals↗
Cystic thyroid lesions in children.
BACKGROUND/PURPOSE: Cystic lesions of the thyroid encompass a wide and heterogeneous group of disease states in children, ranging from benign purely cystic entities to malignant tumors. The purpose of this study was to study both the presentation and management of cystic thyroid lesions in the pediatric population. METHODS: A retrospective review of all thyroid masses presenting between 1978 and 1996 and found to be purely or partially cystic on ultrasound examination was conducted, looking at presentation, family history, laboratory values, ultrasound scan and radionuclide imaging, and pathological and cytological evaluation. RESULTS: Twenty-four patients (19 girls, 5 boys) aged 6 to 18 years received the diagnosis of cystic lesions of the thyroid. Of these, 23 presented with painless neck masses, 21 were clinically euthyroid, only one had a single abnormal thyroid function test, only two had mildly positive antithyroid antibody test results, and nearly 30% had a positive family history of thyroid disease. Ultrasonography showed pure cysts in five patients and mixed solid cystic lesions in 19 patients. On scintiscan, six lesions were hot, 13 were cold, three showed normal uptake, and two were mixed. Treatment included either observation, aspiration, cyst sclerosis, surgery, or combinations thereof. Pathological and cytological results included follicular adenoma (n = 9), cystic degeneration (n = 6), multinodular goiter (n = 4), carcinoma (n = 2), branchial cleft cyst (n = 1), and undetermined (n = 2). CONCLUSIONS: Thyroid cysts are often thought to represent benign degenerative disease. Our study, which is the first in the literature to specifically address thyroid cysts in children, shows that ultrasound scan is useful in evaluating thyroid masses, whereas laboratory and radionuclide are of less value, and that single lesions of mixed echogeneity are likely to represent neoplasms, a significant percentage of which are malignant.
Adolescent↗
Expandable metallic stents in benign tracheobronchial obstruction.
Expandable metallic stents offer advantages over previously available techniques for treating benign tracheobronchial stenosis or obstruction. Endoluminal stent placement offers a rapid and effective means of opening up narrowed airways, and results in excellent relief of symptoms and improvement in pulmonary function. Because they are delivered in a nonexpanded state using flexible over-wire systems, they can be placed using a flexible bronchoscope and can be located in second-order bronchial branches. Metallic stents have been used to treat benign airway obstruction caused by anastomotic narrowing after lung transplantation, infection, congenital lesions, tracheobronchial malacia, inflammatory conditions including relapsing polychondritis, Wegener granulomatosis, and acquired immunodeficiency syndrome, and external compression from benign mediastinal masses or fibrosis. The stents become epithelialized, which prevents migration and permits ciliary activity to continue. Significant complications can occur, including airway inflammation, stent migration, airway erosion, and stent fracture and collapse, but more serious complications are uncommon. Computed tomography is essential in imaging patients being considered for stent placement, as it allows 1) accurate representation of airway anatomy in three dimensions. 2) measurement of airway diameter, 3) evaluation of airway anatomy distal to a narrowed segment and invisible to bronchoscopy, 4) demonstration of dynamic changes in airway morphologic features during forced exhalation in patients with airway malacia, and 5) demonstration of focal or diffuse air trapping in lung peripheral to the abnormal airway. In patients who have had stent placement, computed tomography is valuable in assessing airway morphologic features and dynamics distal to the stent, and can be valuable in assessing stent dysfunction.
Airway Obstruction↗
Interventional radiology steps in for emergencies.
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Adult↗
[Treatment of scoliosis in the adolescent by anterior release and vertebral arthrodesis under thoracoscopy. Preliminary results].
PURPOSE OF THIS STUDY: The purpose was to evaluate short term results of thoracoscopic anterior release and fusion in adolescent scoliosis. MATERIAL AND METHODS: An independent observer reviewed retrospectively hospital files and X-rays of 8 consecutive patients. The average follow-up was 14 months. The mean age at the time of surgery was 12 years old, all patients were skeletally immature. The surgical technique consisted in a thoracoscopic release and fusion of the discs space followed in the same time by a posterior instrumentation and fusion. Six cases were done in the prone position, two in the lateral decubitus. RESULTS: The release could be done in 7 cases. In one case a severe bronchospasm prevented from doing discectomy. Four levels in average could be released and fused. The thoracoscopic time was 240 mn in average and the total surgical time 430 mn. The bleeding of the thoracoscopic procedure was minimal (less than 200 cc) in all but one case (2000 cc). The duration of the chest tube was 4.4 days. At last follow up the cosmetic advantage was obvious. The angular correction of the Cobb angle was 63 per cent (similar to our isolated posterior instrumentation). The radiologic aspect of the anterior fusion seemed to be less satisfactory than the ones of classic thoracotomies (although we did not observe any non union). DISCUSSION: Our experience and these results moderate the initial enthusiasm of these new techniques reported in literature. Our current indications are therefore patients at risk of crankshaft, and complementary anterior fusion of dysplasic spines. As to the major curves we still recommend the anterior release through a formal thoracotomy which allows a more complete disc excision on more levels and a more abundant graft, with a shorter surgical time, with an associated morbidity which does not seem superior.
Adolescent↗
Pediatric surgeons' activities and future plans.
OBJECTIVE: The authors aim was to survey members of the Canadian Association of Paediatric Surgeons (CAPS) on their demographics, practice, and future plans. MATERIALS AND METHODS: A questionnaire was mailed to 86 members. RESULTS: We received 60 questionnaires (70%), with a return rate including 85% men and 15% women. Seventeen percent of the respondents do not have children, 8% did not answer the question pertaining to children, and 8% expect to have more children. Among the 75% of surgeons with children, 16% have reduced the number of hours worked, from 2 hours to more than 1 day per week, for a number of years. Younger surgeons and women are more likely to reduce their work load for their family life. Most surgeons practice in an academic (64%) or a mixed setting (25%), with only 12% involved in private practice. On average, 69% of their time is devoted to patient care; teaching and research each take an average of 10% of the surgeon's time, while 9% of their time is spent on administrative duties. Study respondents work an average of 57 hours per week, and 45 weeks per year. Age significantly influenced the number of hours worked per week, and the number of weeks worked on a yearly basis. Gender and type of practices did not significantly influence the number of hours or weeks worked, whereas location of practice did. Spouse activity also had an impact on the number of hours and weeks worked. When asked about their preference for the next 5 years, 30% of surgeons would opt for a decrease in their level of activity, and 15% wish to retire. Irrespective of the age group or the type of practice, surgeons would prefer to decrease their level of activity. A recurring theme submitted by respondents is the need for increased time for teaching and research and less administrative work. Finally, 60% of surgeons were very satisfied with their work, 27% were satisfied, and 12% were unsatisfied. CONCLUSION: Lifestyle and family commitment have an impact on pediatric surgeons' activity and should be considered when analyzing work force requirements.
Adult↗
The effects of tracheal occlusion and release on type II pneumocytes in fetal lambs.
UNLABELLED: Fetal tracheal occlusion (TO) has been shown to lead to lung hyperplasia in various animal models, and this procedure has already been carried out in human fetuses with congenital diaphragmatic hernia (CDH). However, the authors previously showed that TO caused a decrease in type II pneumocytes. PURPOSE: The aim of this study is to examine the effects of TO and release on type II pneumocytes. METHOD: To was carried out with a Swan Ganz or Fogarty catheter in fetal sheep at 116 to 118 days of gestation. TO was maintained for 2 weeks followed by deflation of the balloon for 1 week before delivery, in group 1; in group 2, TO was maintained for 19 days and released 2 days before delivery. Group 3 consisted of previously reported animals who had TO maintained until birth. Unoperated twins served as controls. All specimens were analyzed using the surfactant protein C (SP-C) mRNA as a specific marker for type II pneumocytes. We used Northern Blot and in situ hybridization techniques to quantify total SP-C and the density of type II cells. Electron microscopy (EM) was also used to evaluate and quantitate type II cells. RESULTS: TO resulted in significant lung growth in all groups. In situ hybridization and Northern Blot analysis showed that there was a complete recovery of type II cells in group 1 versus controls. Quantitative EM analysis confirmed these findings. In group 2 the number of type II cells was decreased but there was an increase in SP-C content per type II cell versus group 3. CONCLUSION: Lung growth after TO appears to occur at the expense of type II cell differentiation. This effect is reversible with the release of TO before birth in this animal model.
Airway Obstruction↗
Empyema thoracis in children: a 26-year review of the Montreal Children's Hospital experience.
The appropriate management of pediatric empyema thoracis remains controversial. The authors reviewed 47 cases of empyema thoracis over a 26-year period. The management of empyema included initial diagnostic thoracentesis and classification as acute, fibropurulent, or chronic. If the empyema was "acute," therapeutic tap, tube thoracostomy, or no surgical intervention was performed. "Fibropurulent" empyemas were uniformly treated with tube thoracostomy. The lung was decorticated when the empyema was encased by a thick peel, had recurred and was multiloculated, was refractory and the patient remained clinically unwell, or had occurred as a complication of previous thoracotomy. All patients with acute empyemas responded to antibiotics irrespective of drainage (average duration of fever, 17 days; average stay in hospital, 27 days). Of the fibropurulent empyemas in our review, complete drainage was attained in seven of 39 (18%), and decortication was not required in any empyema that was completely drained. Loculations persisted in 25 of 39 (64%) after tube thoracostomy but nonetheless resolved. The remaining seven of 39 (18%) with persistent loculations required formal decortication. Of the patients with fibropurulent empyemas that responded to tube thoracostomy, the average duration of fever was 13 days and hospitalization, 23 days. Of those requiring decortication the average duration of fever was 24 days and hospitalization, 40 days. These results will allow a baseline for comparison of new strategies (fibrinolytics and early thoracoscopy) that may reduce days of fever, hospitalization, and risk of formal decortication.
Adolescent↗
The fate of undescended testes in patients with gastroschisis.
Cryptorchidism is frequently associated with gastroschisis, yet little is published on its management in such circumstances. In a review of 10 consecutive boys with gastroschisis since 1980, 4 had undescended testes. Gestational age and birth weight did not differ from the 6 boys with normally descended testes. The first two patients had associated arthrogryposis multiplex congenita. The first underwent bilateral orchidopexy at 9 years of age for inguinal testes. In the second patient, the left testis was intraabdominal at the level of the sigmoid colon at birth; at 3 months of age, when a left inguinal hernia repair was required, left groin exploration revealed the testis at the internal ring and orchidopexy was performed successfully. In the third patient the left spermatic vessels were divided at the time of gastroschisis repair and the testis anchored in the prebubic area. The second-stage orchidopexy was performed at 16 months. In the last patient the intraabdominal testis could be placed in a scrotal pouch without mobilisation or division of the vessels. From our experience and a review of the literature we conclude that: 1) undescended testes are frequently associated with gastroschisis; 2) mechanical factors rather than prematurity are likely responsible for this association; 3) if the testis easily reaches the scrotum, orchidopexy can be done safely at the time of gastroschisis repair; 4) if the testis does not reach easily and appears to have a gubernaculum, it may be preferable to leave it in place since spontaneous descent can occur.
Abdominal Muscles↗
The Bianchi procedure in a patient with jejunal atresia.
While small-bowel transplantation remains an option for the management of short-bowel syndrome (SBS), every effort must be made to optimize the function of the native bowel. This report describes a patient with SBS who dramatically improved after a Bianchi procedure. The patient was born with type IIIb jejunal atresia, complicated by volvulus of the terminal ileum. He was left with 40 cm of small bowel and his ileocecal valve. During the first 20 months of his life, he was always hospitalized except for 3 months. He was on parenteral nutrition (TPN) and suffered multiple episodes of central line sepsis. Massive small-bowel dilatation caused a functional bowel obstruction with bacterial overgrowth, and villous atrophy of the jejunal mucosa was discovered on biopsies done by colonoscopy. In March 1994, we elected to proceed with a Bianchi procedure. Thirty cm of jejunum were divided longitudinally. During the following year, his enteral tolerance steadily improved to the point where TPN could be discontinued. We conclude that pediatric surgeons should not hesitate to use this procedure in the management of SBS.
Humans↗
Deleterious effect of tracheal obstruction on type II pneumocytes in fetal sheep.
It was previously shown that tracheal obstruction accelerated fetal lung growth and eventually reversed the pulmonary hypoplasia in experimental diaphragmatic hernia. We have successfully developed a reversible tracheal obstruction technique in fetal sheep using balloon occlusion and showed that 3 wk of obstruction induced significant lung growth of the same magnitude as the tracheal ligation. The purpose of this study was to examine the effects of 1 and 3 wk of tracheal occlusion on the alveolar cell population with specific attention to the type II pneumocytes. We first showed that 1 wk of occlusion induced a significant increase in lung weight and in alveolar surface area. We then used the surfactant protein C (SP-C) mRNA as a specific marker of differentiated type II pneumocytes. Total RNA was isolated from fetal sheep lung with or without tracheal occlusion, and Northern blots were hybridized with a cDNA probe specific for the sheep SP-C. The results show a dramatic decrease in SP-C mRNA expression (8.8-fold, p < 0.01). In situ hybridization showed a marked decrease in the density of cells expressing SP-C, as well as the amount of SP-C mRNA expressed by the cells. The effect was present as early as 1 wk of occlusion. The sparseness of type II pneumocytes was further confirmed by electron microscopy. We thus conclude that tracheal obstruction causes a profound decrease in the number of type II pneumocytes in the lungs. Given the crucial role of type II pneumocytes in surfactant production, we could speculate that, if tracheal occlusion is able to accelerate lung growth, the final product is probably surfactant-deficient.
Airway Obstruction↗
The anterior sagittal approach to the treatment of anorectal malformations: evolution of the Mollard approach.
Mollard's anterior perineal approach has been used for more than 20 years for the treatment of anorectal malformations and has undergone several modifications. The anterior sagittal approach is a simplification of the Mollard approach. It allows a safe dissection and preservation of the puborectalis sling, a clear identification of the external sphincters and other striated muscle fibers caudal to the puborectalis, and prevents inadvertent damage to the nerve supply. The site of the rectourethral (or rectovaginal) fistula, containing the internal sphincter, is preserved for anastomosis with the anoderm. The rectal cul-de-sac is mobilized minimally to come through the puborectalis under some tension, while the anoderm and external sphincters are also brought up under tension to meet these structures, thereby creating a short anal canal more closely resembling the normal anatomy. This approach can be used for most types of anorectal malformations in both sexes, and usually is combined with a transverse suprapubic laparotomy for supralevator anomalies.
Anal Canal↗
Hirschsprung's disease, imperforate anus, and Down's syndrome: a case report.
Patients with trisomy 21 have a higher incidence of several gastrointestinal anomalies. However, the coexistence of imperforate anus, Hirschsprung's disease, and trisomy 21 had not been reported previously. This report describes the case of an infant girl born with trisomy 21 and imperforate anus, without a fistula, who presented with bowel obstruction 3 months after anoplasty. The obstruction was attributable to Hirschsprung's disease. This was managed by a leveling colostomy in the descending colon, followed by an endorectal pull-through after 4 weeks. She has a normal stooling pattern 11 months after colostomy closure. Hirschsprung's disease should be suspected in infants with trisomy 21 who have constipation after repair of imperforate anus. The authors believe that the endorectal pull-through is the safest technique to use for Hirschsprung's disease after a previous anoplasty.
Abnormalities, Multiple↗
Recurrent intussusception: safe use of hydrostatic enema.
Recurrent intussusception (RI) occurs in 5% to 8% of patients with intussusception. The authors reviewed their 15-year experience to better define the management of RI. Among 258 patients, 28 (10.8%) had episodes of RI (37 episodes altogether). Twenty-two patients had a single recurrence, four had double recurrence, one had triple recurrence, and one had quadruple recurrence. RI and non-RI patients were compared with respect to symptoms. The incidence of vomiting and bloody stools was significantly lower in the RI group. Ten percent of RI patients had lead points. Thirty percent of RI episodes occurred within 24 hours, and 74% occurred within 6 months. The success rate of hydrostatic enema reduction for recurrent episodes was 62.8%, which is comparable to that for the initial episode (68.9%). Among patients with previous surgery, 36.3% of enemas were successful; after previous enema reduction, 75% were successful. There was no complication related to the enema. Enema reduction is safe and has a good success rate in cases of RI, even after previous surgical reduction.
Chi-Square Distribution↗
The anterior sagittal approach for high imperforate anus: a simplification of the Mollard approach.
High imperforate anus is a complex anomaly that requires a combination of careful preservation of native structures and precise anatomic reconstruction for optimal results. Previously the authors used an anterior perineal approach derived from the technique described by Mollard, with generally satisfactory results. The present report describes the authors' refinement of the technique to avoid skin perineal approach, via an anterior sagittal incision, usually is combined with a transverse suprapubic laparotomy. The technique includes division of the external sphincter and longitudinal muscle fibers anteriority, simple dilatation of the puborectalis, and division of the fistula close to the urethra, with preservation of the internal sphincter. The rectal pouch is brought down to the level of the puborectalis, without tapering, and the anoderm is brought up to the level of the rectal pouch to construct a shorter anal canal with a normal anorectal angle. This technique maximally preserves internal sphincter function, preserves specialized anoderm for the anal canal, and avoids extensive pelvic dissection and division of the levator sling. It also facilitates repair in the neonatal period, which may be optimal for long-term continence. The authors have used this technique in five patients, with good anatomic and short-term functional results. The authors believe that the technique provides optimal preservation of native tissues; only minimal destruction and dissection are required for reconstruction.
Anal Canal↗
Salvage of Soave-Boley endorectal pull-through by conversion to a classical Soave procedure.
The endorectal pull-through procedure described by Soave and subsequently modified by Boley to include primary coloanal anastomosis is one of the most commonly performed procedures for Hirschsprung's disease. The Boley modification carries a 5-10% risk of dehiscence of the colo-anal anastomosis. This is generally treated with proximal colonic diversion and delayed revision of the pull-through. We report the use of the original Soave procedure to treat this complication.
Anal Canal↗